Sonia Wadhawan

Anesthetic management of superior vena cava syndrome due to anterior mediastinal mass

Anesthetic management of superior vena cava syndrome carries a possible risk of life-threatening complications such as cardiovascular collapse and complete airway obstruction during anesthesia. Superior vena cava syndrome results from the enlargement of a mediastinal mass and consequent compression of mediastinal structures resulting in impaired blood flow from superior vena cava to the right atrium and venous congestion of face and upper extremity. We report the successful anesthetic management of a 42-year-old man with superior vena cava syndrome posted for cervical lymph node biopsy.

Use of intubating laryngeal mask airway in a morbidly obese patient with chest trauma in an emergency setting.

A morbidly obese male who sustained blunt trauma chest with bilateral pneumothorax was referred to the intensive care unit for management of his condition. Problems encountered in managing the patient were gradually increasing hypoxemia (chest trauma with multiple rib fractures with lung contusions) and difficult mask ventilation and intubation (morbid obesity, heavy jaw, short and thick neck). We performed awake endotracheal intubation using an intubating laryngeal mask airway (ILMA) size 4 and provided mechanical ventilation to the patient. This report suggests that ILMA can be very useful in the management of difficult airway outside the operating room and can help in preventing adverse events in an emergency setting.

Donepezil: A cause of inadequate muscle relaxation and delayed neuromuscular recovery.

A 74-year-old female with diabetes mellitus type II and Alzheimers disease, taking donepezil for 4 months was operated for right modified radical mastectomy under general anesthesia. During the procedure a higher dose of non-depolarizing muscle relaxant was required than those recommended for her age yet the muscle relaxation was inadequate intra-operatively. Residual neuromuscular blockade persisted postoperatively, due to the cumulative effect of large doses of non-depolarizing muscle relaxant, needing post-operative ventilatory assistance. After ruling out other causes of resistance to non-depolarizing muscle relaxants, we concluded that acetylcholinesterase inhibitor donepezil was primarily responsible for inadequate muscle relaxation and delayed post-operative neuromuscular recovery.

Tracheal intubation through Igel conduit in a child with post-burn contracture

Sir, A 25 kg, 9 year old girl was scheduled for post-burn contracture (PBC) neck release and superficial skin grafting following burns. Contracture scar was in the anterior midline of the neck. Neck extension was limited, and interincisor gap was ~ 3.5 cm. All relevant investigations were within normal limits. Standard monitors were attached and intravenous (IV) access was secured on the dorsum of the left hand. Patient was administered glycopyrrolate 0.2 mg, ranitidine 25 mg, metoclopromide 8 mg and fentanyl 50 mcg (IV). Anesthesia was induced with Sevoflurane 2 8% in 100% oxygen (O2) using a size 2 facemask. After adequate jaw relaxation, Igel size 2.5 was inserted, and placement was confirmed by a square shaped capnography wave. Spontaneous ventilation was maintained. An assembly of two uncuffed endotracheal tubes (ETT) of 5.5 mm ID (up to 6 mm ID size, ETT can pass through Igel size 2.5[1]) with connectors removed was created [Figure 1], such that the proximal end of lower tube firmly fitted into the distal end of the upper tube making them a single unit to increase the length of ETT for Igel removal after endotracheal intubation. This assembly was mounted over flexible fiberscope (ED 3.7 mm). Flexible fiberscope with 5.5 mm ID (ETT) over it was kept ready. The surgeon was asked to standby for scar release in an emergency. Depth of anesthesia was maintained with sevoflurane 4-5% in 100% O2.

Management of swine-flu patients in the intensive care unit: Our experience

Background: H1N1 pandemic in 2009–2010 created a state of panic not only in India, but in the whole world. The clinical picture seen with H1N1 is different from the seasonal influenza involving healthy young adults. Critical care management of such patients imposes a challenge for anesthesiologist. Materials and Methods: A retrospective analysis of hospitalized positive H1N1 patients was performed from July 2009–June 2010. Those requiring the ventilatory support were included in the study. Result: 54 patients were admitted in the swine-flu ward during the study period out of which 19 required ventilatory support. The average day of presentation to the health care facility was 6th day causing delay in initiation of antiviral therapy and increased severity of the disease. 65% of the ventilated patients were having associated comorbidities. Mortality was 74% among ventilated patients. Conclusion: Positive H1N1 with severe disease profile have a poor outcome. Early identification of high-risk factors and thus early intervention in the form of antiretroviral therapy and respiratory care will help in reducing the overall mortality.

Anesthetic management of a patient with Montgomery t-tube in-situ for direct laryngoscopy

The Montgomery silicone t-tube used for post-procedural tracheal stenosis has advantage of acting as both stent and tracheostomy tube. The anesthetic management of patient with t-tube in situ poses a challenge. Safe management of such patients requires careful planning. We describe anesthetic management for direct laryngoscopy of a patient with t-tube in situ.

Use of two tracheal tubes and fibreoptic bronchoscope for intubation through a LMA Pro‐Seal® in a difficult paediatric airway

general anaesthetics. A laryngeal mask airway (LMA) was used in 14 cases, a tracheal tube in 19 and a facemask once. Airway difficulties were encountered in five patients, on 12 separate occasions. Eight involved difficult laryngoscopy, two required more than three attempts at LMA insertion and intubation was impossible in two further patients. Adequate laryngoscopy was impossible in one patient because of an immobile tongue and poor mouth opening and in a second, failure to intubate and ventilate was due to fibrous strands stretching from the base of the tongue to the oropharynx. Awake fibreoptic intubation was used to secure the airway in four patients on eight occasions, due to previous difficulties. None of our patients had encountered airway difficulties in childhood and all had undergone tracheal intubation without difficulty for their first surgical procedure in this series. However, by the end of the period, five had encountered airway difficulties and three required fibreoptic intubation. Airway deterioration in adult patients with epidermolysis bullosa has not previously been reported. Isolated difficulties have been reported in children [1–4], but with no failed intubations, and usually a Cormack and Lehane grade 2 or less [5]. Airway difficulties are exacerbated in adults by a repeated blistering– scarring cycle leading to neck contractures, microstomia, poor mouth opening, immobile tongue and oesophageal webs. Our series suggests that the airways of adult epidermolysis bullosa patients may deteriorate over time, although the number of cases was small. The need to achieve safe control of the airway in these patients must be balanced against avoiding frictional trauma. New bulla formation can be associated with difficult or failed airway management [6], LMA insertion, laryngoscopy and use of the facemask [7, 8]. Awake fibreoptic intubation minimises frictional trauma and reduces the risk of new bulla formation whilst safely securing the difficult airway. We believe that fibreoptic intubation is a technique that should be considered for airway control in all adult patients with this unique condition.

Retrosternal goitre: Anaesthetic implications and management

Large retrosternal goitre is a challenge to the anaesthesiologist and the surgeon. We describe the successful anaesthetic management of a 44 year old male patient with extensive retrosternal goitre with severe tracheal compression, operated for total thyroidectomy under general anaesthesia by combined cervical approach and sternotomy. A multidisciplinary team approach with surgical colleagues allowed successful management of the patient. Keywords: Retrosternal goitre, Thyroidectomy, Sternotomy, Awake fibreoptic intubation.

Anesthesia for intellectually disabled

Anesthetizing an intellectually disabled patient is a challenge due to lack of cognition and communication which makes perioperative evaluation difficult. The presence of associated medical problems and lack of cooperation further complicates the anesthetic technique. An online literature search was performed using keywords anesthesia, intellectually disabled, and mentally retarded and relevant articles were included for review. There is scarcity of literature dealing with intellectually disabled patients. The present review highlights the anesthetic challenges, their relevant evidence-based management, and the role of caretakers in the perioperative period. Proper understanding of the associated problems along with a considerate and unhurried approach are the essentials of anesthetic management of these patients.

Entropy vs standard clinical monitoring using total intravenous anesthesia during transvaginal oocyte retrieval in patients for in vitro fertilization

STUDY OBJECTIVE Day care surgery is an important arena for monitors of anesthetic depth where minimizing drug use is essential for rapid turnover. Underdosage, on the other hand, carries the risks of intraoperative awareness and pain. Transvaginal oocyte retrieval (TVOR), often performed under total intravenous anesthesia using propofol and fentanyl in Indian patients, is a procedure of special interest because, in addition to the above concerns, toxic effects of propofol on oocytes have been described. We have studied the role of entropy monitor, a depth of anesthesia monitor, in optomising drug titration and facilitating distinction between analgesic and hypnotic components of anesthesia. DESIGN Prospective randomized controlled study. SETTING Operating theater and postoperative recovery area. PATIENTS One hundred twenty American Society of Anesthesiologists class I and II female patients coming to the IVF centre for TVOR under total intravenous anesthesia using propofol and fentanyl. They were randomly allocated into 2 groups: Group EM (drugs titrated as per entropy values: state entropy and response entropy) and group CM (drugs titrated as per standard clinical monitoring). INTERVENTION None. MEASUREMENTS Total propofol consumption (TP), total fentanyl consumption (TF), on-table recovery time (T1), time to discharge (T2), intraoperative awareness (A). MAIN RESULTS Patients in group EM demonstrated 6.7% lesser consumption of propofol (P= .01), 10.9% more consumption of fentanyl (P= .007) and 1 minute faster recovery on-table (P= .009) as compared to group CM. In the PACU, only 10% patients of group EM required supplemental analgesia as opposed to 28.3% in CM group (P= .01). Time to discharge was similar in both groups and no intraoperative awareness was noted. CONCLUSION Entropy monitor is a useful tool allowing distinction between analgesic and hypnotic components of general anesthesia in patients undergoing TVOR and facilitating drug titration accordingly. Its impact on intraoperative awareness needs to be further evaluated.